P - 78012[ REQUEST FOR ELECTRICAL INSPECTION
1� J�� �- 7 6 2� Minnesota Board of Electriciry -
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104
(651) 642-0800 TTY/MRS 1-800�27-3529 www.electricity.state.mn.us
❑ NEW ❑ REMO _ ❑ ADD ON ❑ REPAIR Describe -using tf� b� of the ite copy if necessary - the work covered by this request:
FEES
SERVICES I I
0 to 400
401 to 8�
IMMUNICATION, REMOTE CONTROL, SIG
CIRCUITS OF LESS THAN 50 VOLTS
iystem Device or Apparatus @ $.50
ADDITIONS TO THE GENERAL FEES
� Transfortner I Power Supply for Signs I OuUi� Lighting @ 35
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes ihe Service andlor Power Supply up to 500 Amperes, All
Circuits and Two Inspec6on Trips Each Dwelling Unit @$60
Additional Inspection Trips (aD S20
InvesGaative Fee
fIFAMILY DWELLINGS PER UNI TOTAL FEE ��
3 to 12 Units @$50 Pe� Unit (minimum total fee is $20) �
Each Additional Unit � 525 *�ns r� F«t irs�cTaa usE aar
I hereby cerEly tlia41 inspetEed the ekv.tical installaUOn described herein on Me dales sfaled:
OTHERADDITIONALFEES ,c,y_ `.rc- ��+
' h6n Retrofit $.25 Fixture
Center Pivot Irtiaafion Boom � S40 R01�"'" wrE
r Z" `"� �
S iallns 'on $.31 Mile
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Request Da[e: Rqrgh�n Inspectlon Required? ❑ Yes ❑ No Inspedion Other Than RaigMn: Ready Now � Will Call
��� � � au must call the inspecta when ready! Date Ready:
I cerMy that I am ttie �,CICENSED CONTRACTOR �COA�ANY ❑ OWNER and hereby request inspection of the electrical work at:
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EB-0OOO1M11 8.1. 2002